Candidate name Assessor name

Date of assessment Assessor position

Age of patient Patient gender Setting

Patient’s problem

1 2 3 4 5 6 7 8 9

1 2 3 4 5 6 7 8 9

1 2 3 4 5 6 7 8 9

1 2 3 4 5 6 7 8 9

1 2 3 4 5 6 7 8 9

1 2 3 4 5 6 7 8 9

7 8 94 5 61 2 3

Candidate and assessor information

Patient information

Candidate assessment criteriaUnsatisfactory Satisfactory Superior

Clinical record keeping

Not observed

Clinical assessment

Management plan – investigations Not observed

Management plan – treatments

Management plan – follow up

Clinical reasoning

Overall competence

Comments Please describe what were effective, what could be improved and your overall impression of the strengths, weaknesses and areas for improvement. If required, please specify suggested actions for improvement and timeline. (Must be completed if candidate did not meet expectations)

Minutes spent observing:

Minutes spent providing feedback:

Test rating

To what degree was this a test of the doctor’s abilities? Inadequate Adequate Superior

Overall performance rating(relative to PGY1)

Signature of assessor:

Date:

Did not meet e xpectations

Case-based discussion assessment form

Met expectations

Signature of candidate:

Date:

Case based discussion information for assessors

Aim of CBDThe CBD is part of a clinical encounter individually observed with a patient.

CBD suggested timeframeThe suggested timeframe is 15 minutes observation and 10 minutes feedback.

Management plan – treatmentInvestigations:

Why did you order these investigations?How did you interpret the test results?Were all the tests necessary in cost-benefit terms?

Management plan – follow upManagement:

________________________________________________________

PGY1 level characteristics (satisfactory level)Characteristics of a candidate who meets PGY1 requirements at a satisfactory level in each dimension may include the following:

___________________________________________________

• Have you described a management plan for each of the key problems?• What was the reason for this therapy written on the treatment chart?• What issues do you consider still need to be resolved?

Clinical reasoning

Clinical record keepingFocus is on the clinical assessment as reflected in the record content details, relevance, comprehensiveness and quality of note keeping, and the reasons behind the clinical decisions and actions.

Clinical assessmentThe focus is particularly on the notes the candidate has made. The assessor explores the candidate’s interpretation of data in the record– the nature of the recorded history, physical examination, clinical summary and problem list.

History:• Tell me what you were thinking about this patient’s

presenting problem.• What did you think was the sequence of events or

underlying process leading up to the presentation?• What other key problems are also current?• Is the history of these other problems relevant to the presentation?• Is the family history of importance for any of the key problems?

Examination:• Have you examined the key systems relevant to the

presenting problem?• What about the findings relevant to the other active clinical

problems?

Summary and Problem List:• How have you or how would you list the problems in terms of

priority?• Are the different clinical problems related in some way?• What are the psychosocial issues here?

Management plan – Investigation treatment (highlights investigation risk.)Investigations:

• Why did you order these investigations?• How did you interpret the test results?• Were all the tests necessary in cost-benefit terms?

Management:• Have you described a management plan for each of the

key problems?• What was the reason for this therapy written on the treatment chart?• What issues do you consider still need to be resolved?

• What are the main considerations in relation to the patient’s discharge plan and future health care?

• What aspects of this patients care did you find challenging?

Assessor encourages the candidate to reveal their clinical reasoning:

What was your reason for ordering that investigation?

Overall clinical competenceA global judgement based on the whole encounter.

Tips for feedbackThe assessor focuses on what they’ve observed. This needs to be specific and precise – focusing on about 3 points only.

Assessor identifies the positive aspects of the CBD:• e.g. I thought your history was thorough and comprehensive

and gave the reader a good understanding of the pathophysiological process leading to the presenting problem.

Assessor encourages reflection:• e.g. I observed that your written history did not include the key

element of the lead up to the presentation. Why do you think…?• e.g. Do you think your examination findings showed an

appropriate assessment of a diabetic patient?e.g. How could your problem list have been improved?

Collegial interaction:• e.g. When thinking about a patient’s problem list we usually try to

give some priority to the list. Do you agree?

Assessor’s appraisal is honest:e.g. In the examination findings I would have expected to see…• e.g. In my opinion the problem list was incomplete and the

important current problems of X and Y were not appropriately considered. Would you agree?

e.g. Yes, you mentioned that… and I would agree with you that..

Assessor asks candidate to consider how they will proceed from here. Assessor checks candidate’s understanding and commitment.That’s really good Marko, we are agreed on a way forward to make your case notes more comprehensive and effective and if you can put all that into action…

P Please refer to the AMC Intern Outcome Statements for more guidance on what is expected of an intern http://www.amc.org.au/joomla-files/images/intern-training/intern-training-intern-outcome-statements-2014-09-24.pdf

For further information on assessment of skills please visit http://wbaonline.amc.org.au/ and the CPMEC Australian Curriculum Framework for Junior Doctors website http://www.cpmec.org.au/files/Brochure%20final.pdf